1 HYDROMORPHONE IN THE ED: NECESSARY ANALGESIC OR UNNECESSARY EVIL? Sergey M. Motov, MD @painfreeED FINANCIAL DISCLOSURE CASE 1 • 75 yom with leg ulcer • Within 4-hours in ED: – MS 2 mg IV, HM 2 mg IV x2 doses – Fentanyl patch • One hour after last dose: – Patient is unresponsive, bradypneic – Naloxone IV, immediate response CASE 2 • 65 yom with 7 mm kidney stone • Over 3-hours in ED: – HM 4 mg IV x 3 doses • Two hours after last dose: – Patient unresponsive – Bradypneic and Bradycardic – IV Naloxone – IV Atropine – Transferred to ICU CASE 3 • 54 yof with acute pancreatitis – MS 2 mg IV at 12 pm and 2 pm in the ED – HM 2 mg IVP at 3 pm, 4 pm, and 6 pm • At 7 pm: – Patient unresponsive – Bradypneic – Naloxone IV – Transferred to SICU
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HYDROMORPHONE IN THE FINANCIAL DISCLOSURE ED: …controversies-and-consensus.com/lectures/9_motov_2017.pdf · 2017-09-19 · Hydromorphone vs. Morphine 0.0075 mg/kg IV vs. 0.05-mg/kg
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HYDROMORPHONE IN THE ED: NECESSARY ANALGESIC OR
UNNECESSARY EVIL?
Sergey M. Motov, MD @painfreeED
FINANCIAL DISCLOSURE
CASE 1 • 75 yom with leg ulcer • Within 4-hours in ED:
– MS 2 mg IV, HM 2 mg IV x2 doses – Fentanyl patch
• One hour after last dose: – Patient is unresponsive, bradypneic – Naloxone IV, immediate response
CASE 2 • 65 yom with 7 mm kidney stone • Over 3-hours in ED:
– HM 4 mg IV x 3 doses
• Two hours after last dose: – Patient unresponsive – Bradypneic and Bradycardic – IV Naloxone – IV Atropine – Transferred to ICU
CASE 3 • 54 yof with acute pancreatitis
– MS 2 mg IV at 12 pm and 2 pm in the ED – HM 2 mg IVP at 3 pm, 4 pm, and 6 pm
• At 7 pm: – Patient unresponsive – Bradypneic – Naloxone IV – Transferred to SICU
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CASE 4 • 82 yom with back pain • Over 5-hours in the ED
– MS 2 mg IVP, HM 2 mg IVP x2 doses
• On the floor: – Lethargic – Bradycardic – Hypoxic: 80% on RA – Naloxone IV, transferred to ICU
CASE 5 • 22 yom with SCD: painful VOC crisis • Over 1 ½ hours in the ED
– HM 6 mg IVP x3 doses • 1h after last dose:
– Unresponsive in the bathroom – Pulseless, PEA arrest – Could not be resuscitated
• Does not provide better analgesia than morphine
• Does cause pruritus and severe respiratory depression
• Does accumulate in patients with renal failure
REALITY OF HYDROMORPHONE
• EM Providers: – Gaps in/lack of understanding hydromorphone efficacy and potency